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The U.S. emergency care system received an overall grade of C- in a new report, the first of its kind, released by the American College of Emergency Physicians at a Jan. 10 news briefing in Washington, D.C. The 124-page state-by-state report, The National Report Card on the State of Emergency Medicine: 2006, found that 80 percent of states had middling or failing grades on 50 performance measures in four broad categories used by an ACEP task force to grade states on their emergency medicine preparedness.

The task force, which started work a year ago, found that the nation's emergency departments and trauma centers are marked by overcrowding, reduced access to care, soaring liability costs, and inadequate capacity to deal with surge situations such as public health crises or natural or terrorist disasters.

The report's four broad emergency medicine categories and their percentages as weighted on a state's final grade were:

▪ Access: 40 percent.

▪ Quality and patient safety: 25 percent.

▪ Public health and injury prevention: 10 percent.

▪ Medical liability environment: 25 percent.

Based on these ratings, no state earned an A on its emergency care report card.

California was first in the nation on performance, and California, Massachusetts, Connecticut, and the District of Columbia all earned high B grades. But the new report found that half the states were providing below-average support for their emergency medical systems, earning them poor or near-failing grades. Those receiving a D, the worst overall grade, were Arkansas, Idaho, and Utah. The task force used available data from a variety of sources, including the U.S. Department of Health and Human Services and the American Medical Association.

“Quite frankly, the results are disturbing,” said Frederick C. Blum, MD, the president of ACEP and an associate professor of emergency medicine and pediatrics at West Virginia University School of Medicine in Morgantown. “This report card should be a national call to action for the public. Let's not let the system collapse before we fix it.”

‘System in Distress’

Dr. Blum said the report reveals “a system in distress,” and that the dire state of the nation's emergency care system is symptomatic of the fact that the U.S. health system itself is gravely ill. He said if the situation is this critical in most of the state's emergency systems now, states will not be prepared to meet the needs of their citizens in a pandemic, another Hurricane Katrina, or a terrorist attack, not to mention the burgeoning health care needs of the country's 76 million aging baby boomers, whom he termed a “demographic time bomb.”

“In a disaster or terrorist attack, we know that 70 percent to 80 percent of patients will go directly to the emergency department for help,” he warned.

While EDs by law must treat anyone who walks through the doors without regard for their ability to pay, Dr. Blum noted that “when a trauma center or an ED closes, it closes for everybody.” Although the ACEP report found a correlation between the general wealth of a state and higher emergency care scores, it also pinpointed historically poor states that earned higher than average grades because of a commitment to excellence in emergency care, such as in South Carolina and West Virginia.

Dr. Blum emphasized that the new report focuses on the overall U.S. emergency system by state, and is in no way meant to be an evaluation of individual physicians or individual EDs. “Emergency physicians and nurses are among the most dedicated people you will ever meet,” he said. He noted that this overworked cadre of professionals is not responsible for the number of EDs decreasing by 14 percent since 1993 while patient visits soared to about 114 million a year.

Medical Liability

“The results are crystal clear. If this were a patient, we'd be putting it in the ICU,” said Angela F. Gardner, MD, the chairwoman of the ACEP task force that produced the report. Dr. Gardner, an emergency physician at the Medical Center of Plano in Texas, noted that a state's report card rating on medical liability environment measures is particularly important because states that have hostile liability environments for ED practice are losing their physicians to states with more favorable liability environments.

This category on the report card assessed increases in state medical liability rates and state medical liability reform efforts. “If they're not leaving, they're restricting their practices,” she noted of physicians in states with unfavorable medical liability milieus. Some states have enacted caps on noneconomic damages in a medical liability suit (often at $250,000), which the report noted creates an environment where good physicians don't feel forced out. ACEP favors federal legislation that would support liability protections for physicians who provide mandated care under the Emergency Medical Treatment and Labor Act (EMTALA).

Four states — California, Montana, Nevada, and Texas — earned As for having favorable medical liability environments. Twelve states received failing grades for having hostile medical liability environments: Arkansas, Connecticut; the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia, and Wyoming. Some states, such as the District of Columbia, which scored high on other performance measures scored poorly on medical liability climate. The District of Columbia Medical Society is seeking medical liability reform because of soaring jury awards to plaintiffs, said the society's communications manager, Jane Moncrief, who attended the briefing.

Dr. Blum said the ED has traditionally been taken for granted by policymakers and the public, and emergency care has not been given the resources to do the job its physicians and nurses are trained to do. Georges C. Benjamin, MD, the executive director of the American Public Health Association and a former emergency physician and ED director, agreed. The perception that the ED is a safety net” for patients with no regular health care is in question, he said. He noted that not only is access to emergency care inadequate in many of the nation's EDs, but the capacity to handle any kind of surge for any reason is also in doubt. Dr. Benjamin said although challenges existed when he was practicing emergency medicine from 1981 to 1995, today “those challenges have increased to the breaking point.”

Gradual Erosion

Dr. Benjamin noted that there has been gradual erosion in ED capacity over the past 10 to 15 years. While the capacity to triage patients still exists, he said, EDs are often backed up. “You're seeing longer waits,” he said. “When I was practicing, having [a patient] in the emergency department overnight was uncommon.” But now, he said, it happens all too frequently. In an interview with EMN after the news briefing, Dr. Benjamin said he noticed a big difference in the demands on the ED since he practiced there, having seen those increased challenges as a patient and as someone taking people to the ED. Today, he said, people are coming to the ED “much sicker and in greater numbers than when I was practicing.”

Both Drs. Blum and Benjamin emphasized that the majority of states need to better educate people on public health issues and injury prevention, which can reduce the need for ED visits. Forty-one states earned a C or lower on their support for health and safety programs, and Montana and South Dakota earned Fs.

In a related development, Advocates for Highway and Auto Safety, an alliance of insurance companies and consumer, health, safety, and law enforcement organizations, released data showing severe gaps in key highway safety laws by state just days before the ACEP news conference. According to the alliance, there has been little improvement in reducing motor vehicle crashes, which continue to cause nearly 43,000 U.S. deaths and three million injuries every year, costing the nation more than $230 billion. The alliance report said 28 states still need to adopt a primary enforcement seat belt law; 30 states do not require all-rider helmet law protection, and no state passed a motorcycle helmet law in 2005. Only 11 states and the District of Columbia, the report said, have the recommended optimal child booster seat law.

For more on the ACEP report on the state of U.S. emergency medicine, go to www.acep.org.

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